Old #4 Rod , Gun and Snowmobile Club Inc.

P. O. Box 679

Charlestown, NH 03603

New Member ______    Renewing Member______ 

July 2008 - July2009

Membership

Name_________________________________________________Age_______DOB_________

Address_____________________________________________Phone____________

City____________________________________State__________Zip____________

E- mail___________________________________Occupation___________________

Range              ______      $30.00

Snowmobile    ______      $30.00  (Includes NHSA dues)

Combination  ______     $50.00 (Includes NHSA dues)

($10.00 of your monthly membership dues entitles you to membership in NHSA and a 1(one) year subscription to Sno-Traveler magazine) 

Amount Pd. $______________

Do you need X-tra Cards for Family Members?

Family Members:

_____________________________________________________Age:_______________

_____________________________________________________Age:_______________

_____________________________________________________Age:_______________

“Family members” are defined as immediate family (spouse, children) living in the household under the age of 18. Family members over the age of 16 may receive a membership card. Anyone under the age of 18 must be in the company of an adult club member, while at the range.

 *****NOTICE*****

When you receive your membership card, you will also receive information regarding range regulations and hours. You are agreeing to abide by those rules when you accept your membership card. If not in agreement, immediately return membership package to the above address for a full refund.

Would you be willing to help if contacted? Please circle all that apply.